Management of cesarean scar pregnancies: Experience of a level II maternity unit

Background: Cesarean Scar Pregnancy (CSP) is a rare but potentially life-threatening form of ectopic pregnancy, whose incidence is rising in parallel with cesarean delivery rates. Prognosis depends on early diagnosis and appropriate treatment. We aimed to report our experience in the management of CSP and to evaluate the outcomes of different therapeutic modalities.

Methods: We conducted a retrospective, descriptive and analytical study including 30 patients with CSP managed in the Department of Obstetrics and Gynecology, Menzel Tmim Regional Hospital, Tunisia, between January 2022 and December 2024 (3-year period). During this period, approximately 8,000 pregnancies were followed in our department. Demographic, clinical, ultrasonographic, therapeutic, and outcome data were collected from medical records and analyzed.

Results: Mean age was 34 years (26–43). All patients had at least one previous cesarean section (two prior cesareans in 70% of cases). The most frequent presenting symptom was isolated vaginal bleeding (60%). Two patients (7%) presented in hemorrhagic shock. Mean gestational age at diagnosis was 7 weeks + 4 days, with a mean initial β-hCG of 42,000 IU/L. Transvaginal ultrasound identified 12 type I (endogenic) and 18 type II (exogenic) CSPs, with a mean residual myometrial thickness of 2.1 mm. Type I CSPs were managed medically in 8 cases and by combined treatment in 4 cases. Type II CSPs were managed surgically in 15 cases, medically in 2 cases, and

by combined treatment in 1 case. The overall uterine-preservation rate was 90%. Major complications were observed exclusively in type II CSPs and included intraoperative hemorrhage > 500 mL (n = 4), blood transfusion (n = 3), and hemostatic hysterectomy following uterine rupture (n = 1). Four subsequent pregnancies occurred within one year, including one CSP recurrence.

Conclusion: CSP should be suspected in any early pregnancy in women with a prior cesarean delivery. Early ultrasound diagnosis and individualized management based on a decision algorithm integrating residual myometrial thickness and trophoblastic vascularity allow uterine preservation while minimizing maternal morbidity.